HomeMy WebLinkAboutSeptic Pumping Slip - 150 BRIDGES LANE 4/11/2016 Commonwealth of Massachusetts
s r City/Town of .
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tem Pumping.Record-
Form 4 iMM O r��� .�JiA11[)O`dE
DEP has provided this form for use.by local Boards of Health. Other forms may be'used, but the
information must be substantially the same as that provided here. Before using.this form, check with your
local Board of Health to determine the form they use. The System Pumping Record must be submitted to
the local Board of Health or other approving authority.
A. Facility. Information
I. System Location: Left/Right front of house / ig rea_ofw house, Left/right side of house, Left/
Right side of building, Left/Right front of bul •g, Left/Right rear of building, Under deck
Address
City/Town State Zip Code
2. System Owner:
Name'
Address(if different from location)
City/Town State _ Zip
Telephone Number
. Pumping Record
1, Date of Pumping 2. Quantityµtity Pumped: Gallons --
3.
Type-of,system: ❑ Cess col tic Tank
p �s) Septic El Tight Tank
❑ Other(describe):
4. Effluent Tee Filter present? ❑ Yes o If yes, was it cleaned? ❑ Yes ❑ No,
5. Condition of System:
6; System Pumped By:
Neil.Batesan F5821
Name Vehicle License Number
Bateson Enterprises Inc-
Company
7. L7ZL p where contents were disposed:
`S: � Lowell Waste Water
� M
Sign a Haule Date `
t5form4.docd 06/03 System Pumping Record•Page 1 of 1